Do you Speak Ocular Tumor?

Journals and Societies:

We have had great success adding commitments from our journals and societies. Most all the major ophthalmic journals require or suggest the use for the 7th edition AJCC-UICC tumor staging to their instructions for authors. We expect this tradition to continue for the 8th edition.

If you don't see the AJCC in some of these links, it is because they haven't gotten to it yet. Check again in a few weeks. This list includes most of the major western ophthalmology journals and the societies they represent. We are pleased with the work of our committee and thank you for your support.

Founded in 1854 by Albrecht von Graefe this journal is the official publication of the Club Jules Gonin, International Society of Ocular Trauma, Deutsche Ophthalmologische Gesellschaft and the German Ophthalmology Society.

“EYE CANCER CLASSIFICATION AND STAGINGAuthors of clinical papers should use the Tumor, Node, Metastasis (TNM) classification and staging system approved by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC), whenever applicable. If another staging system is stated, the TNM equivalent should also be given. When a stage or classification is used in the manuscript, a reference citing the staging system must be provided. For the most recent system, see AJCC Cancer Staging Manual, 7th Edition, or the UICC TNM Classification of Malignant Tumours, 7th Edition, Springer, New York."

AJO Wording

N. CANCER CLASSIFICATION SCHEMEAuthors should use the American Joint Commission on Cancer classification scheme when describing patients with ophthalmic malignancies; see American Joint Committee on Cancer. AJCC Cancer Staging Manual, Seventh Edition, Springer, New York.

But, the journals aren’t the only venues adopting the AJCC-UICC TNM Classification System:

UICC Member Organizations:

International Union Against CancerThere are 103 member organizations of the International Union Against Cancer (UICC). They include 27 from Africa, 74 from Asia and the Pacific, 91 from Europe, 41 from Latin American and the Caribbean, 20 from the Middle East, 40 from North America and 5 that span the world.

Why should our journals and organizations help?

Language is defined as the human use of spoken or written words as a communication system. Sharing a common language allows us to communicate our ideas and enables progress.

With this in mind, the American Joint Committee on Cancer (AJCC), the International Union Against Cancer (UICC), and the American College of Surgeons (ACS) have come together to sponsor a committee to design a clinically useful TNM (Tumor-Node-Metastasis) based classification for ocular tumors. The AJCC classification system can be used as a universal language for those who diagnose and treat ocular tumors.

Chaired by Paul T. Finger, MD, the AJCC-UICC committee of physicians included specialists in ophthalmic pathology, ocular plastic surgery, intraocular, orbital, and adnexal tumors. Dr. Finger "Internationalized" the committee as to include 7 members from the USA and 8 from other countries.

These included members of the UICC and others with particular expertise based on a review of the published literature. The training of committee members includes: clinical ophthalmic oncology, ophthalmic pathology, molecular biology, genetics, retinal surgery, orbital surgery and biostatistics. In addition, in a peer-review process, over 20 external reviewers have been involved shaping this work.

All specialists were familiar with current methods of diagnosis and treatment. Thus, every attempt was made to create a clinically useful TNM-based classification system. TNM also means that these classifications conform to what is used throughout medicine, for other tumors and in tumor registries around the world. Clearly, the use of the AJCC-UICC TNM classification would bring ophthalmic oncology into the mainstream of cancer research.

Why should we all adopt a single classification system for ocular tumors?

Until we all use the same classifications of ocular tumors, our studies are not directly comparable and the accuracy of meta-analysis is degraded. If we all decide to “speak ocular tumor,” we will embrace an opportunity to allow for accurate comparisons of our investigational studies.

In 1997, Dr. Finger's review of the literature on “Radiation Therapy for Choroidal Melanoma,” pointed out that no two centers (outside the Collaborative Ocular Melanoma Study [COMS]) published using the same tumor classification. 2 It was not possible to state that tumors of equivalent size and location were irradiated at each center.

Though important information was obtained by comparing multiple phase-I clinical studies, if all the investigators had used the same tumor-classification-language, it would have improved this comparative analysis. It was not until the COMS that over 40 centers used the same definitions (classifications) of choroidal melanoma size, methods to document location, and radiation dosimetry. 3 In fact, the COMS is an excellent example of how a staging system can be used at multiple institutions to allow treatments to be directly comparable and additive. But, the COMS only studied choroidal melanomas. In contrast, the AJCC classification provides clinically useful definitions of tumor size, location and metastatic disease for almost all ocular cancers. 4

Why is it important to compare research studies?

We all know that the wheels of progress grind exceedingly slow, but having a common ocular tumor language is an opportunity to grease that wheel. If we all use a common classification for ocular tumors, we will be able to compare treatments on equivalently sized and “staged” tumors. Such information has the potential to improve both our research and clinical decisions.

Advocates for the AJCC-UICC classification suggest that when a researcher publishes on new treatment, the reader should be able to discern the relative size, location, and distribution of the tumors treated. Thus, independent clinical studies can be found to be either additive or dissimilar. Our clinical and research decisions are based on ideas and studies and what we have heard in lectures or read in the literature. Clearly, these decisions are only as good as the information we acquire.

Can speaking “Ocular Tumor” affect informed consent?

Absolutely! Much of our time as clinicians is spent explaining the current knowledge and ophthalmic practice to our patients. A typical explanation of the risks and benefits includes what has been proven by statistics-based-research and what is offered as traditional practice. For example, the Reese-Ellsworth classification categorized the size, location and distribution of retinoblastoma in order to prognosticate the effect of external beam radiation therapy.5 Similarly, the AJCC-UICC tumor classifications will allow us to tell our patients that tumors of certain sizes and/or locations are more or less likely to respond to treatments and/or exhibit side effects.

How can we get everyone to employ this common language?

The AJCC-UICC classification should become mandatory for peer-reviewed publications. This could be done through the instructions for authors (as have other structural elements). We also request that our scientific organizations (e.g. AAO, ARVO, ISER, ASOPRS, ISOO and others) require that scientific data be submitted in the AJCC-UICC format. This may sound a bit drastic, but the editors of the major journals and officers of our organizations could make this decision to the benefit of our profession. We also request that our hospitals require that all tumors be AJCC-UICC staged prior to surgery. This would simplify the task of tumor registries all over the world. The data from tumor registries can be used to monitor both the incidence and prevalence of eye cancers.

We hope that peer reviewed journals, web sites, organizations and lay publications support this effort. If the world-wide ophthalmic community learns how to speak and publish in “Ocular Tumor,” we will better understand each other’s work and more effectively help our patients with eye cancer.